A nurse is caring for a client who gave birth 2 hr ago.
The nurse notes that the client's blood pressure is 60/50 mm Hg. Which of the following actions should the nurse take first?.
Evaluate the firmness of the uterus (fundus).
Obtain a type and crossmatch.
Administer oxytocin infusion.
Initiate oxygen therapy by nonrebreather mask.
The Correct Answer is A
The correct answer is choice A.
Choice A rationale:
Evaluating the firmness of the uterus (fundus) is the first action the nurse should take when a client’s blood pressure drops postpartum. A soft or “boggy” uterus can indicate uterine atony, a leading cause of postpartum hemorrhage, which can lead to hypotension.
Choice B rationale:
Obtaining a type and crossmatch is important if the client needs a blood transfusion, but it is not the first action the nurse should take.
Choice C rationale:
Administering oxytocin infusion can help contract the uterus and control bleeding, but the nurse should first assess the uterus.
Choice D rationale:
Initiating oxygen therapy can help if the client is hypoxic, but the nurse should first assess the uterus.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is choice B.
Choice A rationale:
Placing a baby on their stomach while sleeping is not recommended due to the risk of Sudden Infant Death Syndrome (SIDS).
Choice B rationale:
Removing extra blankets from the crib is a safety measure to prevent suffocation and overheating, which can lead to SIDS.
Choice C rationale:
Padding the mattress in the crib can pose a suffocation risk for the baby.
Choice D rationale:
It’s recommended for newborns to sleep in the same room as their parents for at least the first six months to reduce the risk of SIDS.
Correct Answer is ["A","E","F"]
Explanation
The correct answers are choices B, E, and F.
Choice A rationale:
Nausea with vomiting during the first trimester is a common symptom of pregnancy and does not need to be reported immediately to the health care provider.
Choice B rationale:
Sudden leakage of fluid during the second trimester could indicate premature rupture of membranes, which can lead to infection and preterm labor. This should be reported immediately.
Choice C rationale:
Urinary frequency in the third trimester is a common symptom of pregnancy due to the growing uterus putting pressure on the bladder.
Choice D rationale:
Backache during the second trimester is a common symptom of pregnancy as the body adjusts to the growing uterus.
Choice E rationale:
Lower abdominal pain with shoulder pain in the first trimester could indicate an ectopic pregnancy, which is a medical emergency and should be reported immediately.
Choice F rationale:
Headache with visual changes in the third trimester could indicate preeclampsia, a serious condition that can lead to seizures, stroke, and other complications. This should be reported immediately.
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